Concussion: Scope of the problem, diagnosis, referrals · 2017-12-11 · Concussion: Scope of the...
Transcript of Concussion: Scope of the problem, diagnosis, referrals · 2017-12-11 · Concussion: Scope of the...
Steven R. Flanagan, M.D.
Professor and Chairman
Department of Rehabilitation Medicine
NYU School of Medicine
Rusk Rehabilitation
NYU-Langone Health
Concussion:
Scope of the problem,
diagnosis, referrals
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Disclosures
•Grant support from
•Brain Injury Association of America
•NIH
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Learning Objectives
•At the conclusion of this presentation, participants will be
able to
• Describe basic epidemiology and pathology of
concussion
• Discuss limitations in making a conclusive concussion
diagnosis
• Discuss why and when to make referrals for treatment
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Epidemiology•Incidence (increasing)•521/105(2001) – 824/105 (2010)
•75% Mild
•Increased risk for Age 0-4,
15-19 and ≥75
•2.5 Million Emergency
Department visits-
hospitalizations-deaths/year•0-4 year-highest rated of ED
visits
•Prevalence•3.2-5.3 million, 145K in
pediatric (under-reported)
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Cause of Injury
•Traffic Related•Highest rate 15-24 y/o
•Highest rate of mortality
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Cause of Injury
•Traffic Related
•Falls• Increased incidence with end of age spectrums•Latest CDC data reports falls as most common cause•Highest risk:•0-4•75 and older
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Cause of Injury
•Traffic Related•Falls
•Recreational•Sports•Chronic Traumatic
Encephalopathy
• Incidence not clearly
delineated•Reported under other
categories
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Cause of Injury
•Traffic Related•Falls• Increased incidence with advancing age
•CDC data reports falls as most
common cause
•Recreational•Sports•Chronic Traumatic
Encephalopathy
• Incidence not clearly
delineated
•Blunt trauma•“struck by or against”
•Most common in 0-4 year
old group
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Cause of Injury
•Traffic related•Falls• Increased incidence with advancing age
•CDC data reports falls as most
common cause
•Recreational•Sports•Chronic Traumatic
Encephalopathy
• Incidence not clearly
delineated
•Blunt trauma•Assault•More common in urban areas• Less than falls, traffic related and
blunt trauma
Cause of Injury
•Abusive TBI
•Likely under-reported
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Military Service
•Etiology
•Similar to other populations
•80% in non-deployed settings
•Blast exposure
•DoD estimate
•235K 2000-2011
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How Common are Sport
Concussions in the United States?•Estimated up to 3.8 million occurrences/year
•Many are likely unrecognized, not reported or
misdiagnosed
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Are all injured athletes identified?
•Talavage TM et al: J Neurotrauma 2010
•High school varsity/JV football players
•Dx’d with concussion:
•Altered ImPACT and fMRI
•Not dx’d with concussion but high # or high
magnitude collisions
•Altered ImPACT and fMRI
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CONCUSSION DEFINITIONS
Diagnosis
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American Congress of
Rehabilitation Medicine
•Traumatically induced alteration in brain function,
manifested by at least one of the following
•Loss of consciousness
•Memory loss either before or after the event
•Feeling Dazed or Confused
•Focal neurological finding
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Consensus Statement on Concussion in Sport: the
5th International Conference on Concussion in Sport
Berlin 2016
A sport related concussion (SRC) is a traumatic brain injury induced by biomechanical
forces. Several common features that may be utilized in clinically defining the nature of a
concussive had injury include:
caused wither by a direct blow to the head, face, neck or elsewhere on the body
with an impulsive force transmitted to the head,
typically results in the rapid onset of short-lived impairments of neurological
function that resolves spontaneously, However, in some cases, signs and symptoms
evolve over a number of minutes to hours.
may result in neuropathological changes, but the cute clinical sign and
symptoms largely reflect a functional disturbance rather than a structural injury and, as
such, no abnormality is seen on standard structural neuroimaging studies.
results in a range of clinical signs and symptoms that may or may not involve
loss of consciousness, Resolution of the clinical and cognitive features typically follows a
sequential course, However, in some cases symptoms may be prolonged.
The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use,
other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.) or other
comorbidities (e.g. psychological factors or coexisting medical conditions).
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Concussion
• Complex process resulting from an impulsive blow-can be to body or head
• Any new neurological symptom like headache, dizziness, fogginess
• Loss of consciousness in less than 10%
• Nearly 4 million a year, may be an underestimation
Br J Sports Med 2005;39:196
Slide courtesy of Steven Galleta, MD
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Definition: CDC 2003
• Impact or forceful motion (acceleration / deceleration) resulting in
a brief alteration of mental status, such as confusion or
disorientation, loss of memory for events immediately before or
after the injury, or brief LOC <30 min
More severe TBI are associated with extended periods of
unconsciousness (more than 30 minutes), prolonged PTA (more
than 24 hours), or penetrating skull injury.
• Observed signs of neurological or neuropsychological
dysfunction
• Headache, dizziness, irritability, fatigue or poor concentration,
when identified soon after injury, can be used to support the
diagnosis of mild TBI, but cannot be used to make the diagnosis
in the absence of LOC or altered consciousness.
Concussion Guideline Task Force:
Executive Summary
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A concussion is a change in brain function after a force to the head that may be accompanied by
temporary loss of consciousness but is identified in awake individuals with the use of measures of
neurologic and cognitive dysfunction.
Indicators of concussion, observed in alert (alert: Glasgow Coma Scale Score, 13 to 15) individuals
after a force to the head, are the following:
• Observed and documented disorientation or confusion (disorientation or confusion: loss of one's
sense of direction, position, or relationship with one's surroundings) immediately after the event
* Impaired balance (balance: a state of body equilibrium) within 1 day after injury,
* Slower reaction time (reaction time: the interval of time between application of a stimulus and
detection of a response) within 2 days after injury, and
* Impaired verbal learning and memory (verbal learning and memory: the acquisition, retention, and
retrieval of verbal material; memory of words and other abstractions involving language) within 2
days after injury.
Axons-like telephone wires
Stretching the axons
Slide courtesy of Steven Galetta, MDRUSK REHABILITATION
Axonal transport interruption,
swelling and disconnection, like an
Earthquake has occurred to a
Highway- you get a big traffic jam
Slide courtesy of Steven Galeta, MDRUSK REHABILITATION
Pathophysiology
•Children are different from adults
•Cerebral water content
•Extent of myelination
•Cerebral blood flow
•Skull properties
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YOU LOOK FOR WHAT YOU
KNOW
You see what you look
for,
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CONCUSSION ASSESSMENT
Clinical Presentation and Evaluation
History
•Trauma to head or body
•Other factors to consider•Whiplash
•Psychiatric
•Previous concussions
•Social
Symptoms
•Physical
•Cognitive
•Behavioral
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It should all make sense
You see what you look for,
You look for what you know
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No diagnostic test for concussion
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Physical Examination
SCAT 3•Brief Neurological and MSK
Examination•Brief cognitive screen
•Balance
•Coordination
•Sensation
•Limb strength
Deeper look
•Cranial Nerve• I-XII
•Visual•Rapid picture naming
•Vestibular•Dix-Hallpike
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Anosmia
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Loss of smell and taste
Benign Paroxysmal Positional Vertigo
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Concussion Recovery
• Typically fairly rapid
• Watchful waiting
• To rest or not to rest
•NO return to sport-related activity until medically cleared
•Dr. Kerr to discuss Berlin Guidelines
•Otherwise, activity as tolerated
•Dr. Rieger to discuss return school, sports and beyond
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Slower to Recover
•Consider
•Multiple concussions
•Time course of previous injury(ies)
•Cervical injury
•Mood disorder
•Endocrine Dysfunction
•Social Stress
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Referrals to consider
•Emergency Department
•Nausea, vomiting, marked arousal problems, focal deficits
•Parents tend to know when their child is not right
•Physical therapy
•Cervical spine, paraspinal and upper back musculature pathology
•Vestibular therapy
•Neuro-ophthalmology
•Persistent visual complaints
•Vision therapy
•Psychology/Neuropsychology
•Persistent cognitive difficulties
•Supportive therapy
•Accommodation plan for return to school
•Neuroendocrine
•Emerging evidence of pituitary dysfunction
•Not well studied in pediatric populations
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Summary
•TBI/Concussion is common
•Small percentage of mild TBI develop chronic
problems
•Referrals as needed
•Neurological change
•Treatment for those slow to recover
•Much remains to be learned re:
•Objective diagnosis
•Effectiveness of treatments
•Proper identification
•Definitions
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Thank you!
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